Download MBBS Physical Medicine and Rehabilitation Presentations 10 Gait Lecture Notes

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& ASSESSMENT

GAIT

1- Normal Walking

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2- Gait cycle ? phases, temporal parameters
3- Determinants of gait
4- Kinematic & kinetic analysis
5- Gait in young, elderly & women
6- Some abnormal gaits

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7- Assessment ? visual, video recording
8- Clinical Gait laboratory
Walking

Walking

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- complex interaction of different parts of body
- it's advancement in the desired line of progression.
Muscle act - this motion and forces are controlled
Normal walking ?
- weight bearing stability and

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- progression over the supporting foot
- optimal conservation of physiologic energy.

GAIT CYCLE :- Activity that occurs between heel

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strike of one extremity and subsequent heel strike

same side.

STANCE PHASE :- Phase in which limb is in contact

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with the ground. (60%)

SWING PHASE :- Phase in which the foot is in air for

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limb advancement. (40%)

DOUBLE SUPPORT: When two extremities are in

contact with the ground simultaneously

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- cadence (speed of walking) - double support
- Absence of double support - running

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DEFINITIONS

Initial contact: (0%) Instant the foot contacts the

ground.

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Loading response: (0-11%)
- immediately following initial contact - lift of C/L

extremity from ground

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- weight shift occurs.


Subphases of Stance phase

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Mid- stance: (11-30%)
- lift of C/L extremity from ground - ankles of both

extremities are aligned in the frontal (coronal) plane.

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Terminal stance: (30-50%)
- ankle alignment in frontal plane - just prior to initial

contact of C/L extremity.
Preswing: (50-60%)

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- initial contact of C/L extremity - prior lift of Ipsilateral

extremity from ground.

Sub phases of Swing phase

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Initial swing: (60-73%) Lift of the extremity from

ground - position of maximum knee flexion.

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Mid swing: (73-87%) Immediately following knee

flexion - vertical tibia position.

Terminal swing: (87-100%) Following vertical tibia

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position - just prior to Initial contact.


Temporal Gait Parameters

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Stride length: Linear distance between corresponding

successive points of contact of the same foot

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- Highly variable - normalized by dividing it by leg

length or total body height

- increases as the speed increases.

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Step length: opposite foot
- gait symmetry.

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Cadence: No. of steps/minute
Velocity (meters/minute): Distance covered in given

time in the given direction.

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Step width (width of walking base):
- Distance between the midpoints of the heel of two

feet

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- increases - increased demand for side to side stability.

Degree of toe-out:
- Represents the angle of foot placement
- Angle between the line of progression and the line

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intersecting the centre of heel and the second toe

- decreases as the speed increases
Temporal gait parameter

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Average value

Velocity (m/s)

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0.9 ? 1.5

Cadence (steps/min)

90 - 135

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Stride length (m)

1 ? 1.5

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Step length (cm)

38

Walking base (cm)

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6 - 10

Degree of toe-out

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7?

Stance phase

60%

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Swing phase

40%

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Double limb support

20%

Determinants of Gait (Saunders 1953)

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Optimizations to minimize excursion of centre of

gravity (COG), hence reduction of energy consumption

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1. Pelvic rotation

2. Pelvic tilt

3. Knee flexion in stance

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4. Ankle PF

5. Foot supination

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6. Lateral displacement of the pelvis

?

Determinants 1 - 5 reduce displacement on the

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vertical plane (50%)

?

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determinant 6 - horizontal plane (40%).

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GROUND REACTION FORCE (GRF)- When a person

takes a step, forces are applied to the ground by the

foot and by the ground to the foot (GRF)

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- equal but opposite
- GRFVector = sum of the force components in each

direction (vertical, anteroposterior and mediolateral

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axes)

- typical pattern from initial contact to toe-off.
MOMENTS (Torque/ turning force)-

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External forces - GRF, gravity and inertia - external

moments about the joints.
Internal moments - moments generated by the

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muscles, joint capsules, and ligaments - countract the

external forces

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Muscle activity
Kinetics and Kinematics

Kinetics : Study of forces, moments, masses and

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accelerations, but without any detailed knowledge of

the position or orientation of objects involved.

Kinematics : Describes motion, but without reference

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to forces involved.

Trunk and Shoulder

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Trunk along with shoulder girdle twists in opposite

direction of pelvic twist

Total excursion of trunk is 7? and pelvic girdle 12?.

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Total ROM of shoulder is 30? (24? of extension and 6?

of flexion)

Center of gravity (COG) is located 5 cm anterior to

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second sacral vertebra

It is displaced 5 cm horizontally and 5 cm vertically

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during a gait cycle.
Gait in children

Children have no heel strike, initial contact being

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made by flatfoot (2 yr)

Very little stance phase knee flexion (2 yr)
Whole leg is externally rotated during swing phase (2

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yr)

Walking base is wider (4 yr)
Absence of reciprocal arm swing (4 yr)
Stride length and velocity are lower and cadence

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higher (15 yr)

GAIT IN ELDERLY

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Decreased stride length and cadence
Increase in walking base
Reduction in total range of flexion and extension of

joints

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GAIT IN WOMEN
Gait speed is slower
Step length is smaller
Increased cadence

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ABNORMAL GAIT

Any deviation from normal pattern of walking

Caused

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- motor system
- skeletal supports
- neural control
- combination of the above.

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PAINFUL/ANTALGIC GAIT HIGH STEPPAGE GAIT

Avoidance of weight bearing

weakness of ankle

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on the affected limb

dorsiflexors

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shortening of stance phase in

excessive knee and hip

that limb

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flexion with toes pointing

downwards in the swing

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phase


VAULTING

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Seen in limb length

discrepancy, hamstring

weakness or extension

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contractures of the knee

The knee is hyper-

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extended and locked at

end of stance phase and

entire swing phase.

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So to clear the leg the

patient goes up on the toes

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of the other leg to clear the

affected limb.

TRENDELENBURG GAIT

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The gluteus medius during

the stance phase, pulls the

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stance side pelvis over the

supporting limb to prevent

excessive pelvic drop in the

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opposite swing limb.

If the hip abductors are

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weakened, the opposite limb

pelvis may drop excessively

during swing phase.

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To avoid this, the entire

trunk shifts to the stance side

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to bring the stance pelvis on

to the supporting limb.

This is known as gluteus

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medius lurch or

trendelenburg gait.

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MYOPATHIC GAIT

If both hip abductors are

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weak, the trunk sways

from side to side during

the stance phase to bring

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the pelvis level on the

supporting limb.

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waddling gait.
muscular dystrophies
accompanied by excess

lumbar lordosis to

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compensate for hip

extensor weakness.

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HEMIPLEGIC GAIT

In extensor synergy -
?heel strike is missing and patient lands on forefoot
?Since hip and knee are kept extended throughout the

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gait cycle, there is relative limb lengthening and

hence circumduction or hip hiking is used for

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clearance

?Toe drag may be present in swing phase
?Swing phase is longer on the affected limb
?Decreased arm swing on the affected side.

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If flaccid paralysis or flexor synergy is present
?knee buckling and instability


FESTINATING/PROPULSIVE

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GAIT

Lack of arm swing
Short, quick steps with

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increasing speed

Cannot stop abruptly or

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change directions

Stooped posture
Seen in
Parkinsonism

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Carbon monoxide

poisoning

ATAXIC GAIT

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Seen in cerebellar lesions
Dysmetria and inco-

ordination

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Staggering and lack of

smooth movements

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(reeling or drunken gait)

Falls to the side of lesion
Compensated by wide-

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based gait to increase

base of stability
STOMPING GAIT

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Seen in sensory ataxia
Gait with heavy heel strikes, forceful knee extension

and improper foot placement as well as a postural

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instability

Usually worsened when the lack of proprioceptive

input cannot be compensated for by visual input, such

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as in poorly lit environments.

Friedreich's ataxia, pernicious anemia, tabes dorsalis,

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spinal cord pathologies

CEREBRAL PALSY GAIT

Crouch gait

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?Hip and knee increased flexion throughout stance

with ankle dorsiflexion

?Due to hamstring tightness

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Jump knee gait
?Flexion at hip and knee and ankle equinus is

characteristic of this gait

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GAIT IN CEREBRAL PALSY

Stiff knee gait

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?excess knee extension throughout swing
?Has to use circumduction or vaulting
?Due to increased rectus femoris activity in swing

phase

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Recurvatum knee
?Due to triceps spasticity or hamstrings transfer
?Leads to increased knee extension in mid & late

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stance

SCISSORING GAIT

Spasticity of the hip

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adductors with relative

weakness of hip abductors

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and secondary changes in the

hip gives rise to

rigidity and excessive

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adduction of the leg in swing

plantar flexion of the ankle
increased flexion at the knee

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adduction and internal

rotation at the hip

Diplegic CP, Spinal cord

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pathologies


METHODS OF GAIT ANALYSIS

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VISUAL GAIT ANALYSIS

The simplest form of gait analysis.
Look for:

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Symmetry and smoothness of movements
Balance
Degree of effort
Motion of specific segments
Gait parameters

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Gait should be observed from at least 3 angles (side,

front & back)
Limitations-
- gives no permanent record

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- eyes cannot observe high-speed events
- only possible to observe movements not forces
- depends entirely on the skill of the individual observer.

Gait analysis walkway

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- Length ? 10-12 m
- Width - visual - 3 m

video recording - 4 m
kinematic system - at least 6 m.

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ANALYSIS BY VIDEO RECORDING

Advantages-
- gives permanent record

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- can observe high speed events
- reduces the number of walks a subject needs to do
- makes it possible to show the subject exactly how they

are walking

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- makes it easier to teach visual gait analysis to

someone else.

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The majority of today's domestic cameras are perfectly

suitable for use in gait analysis

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Clinical Gait laboratory

A fully equipped clinical

Equipment may also be

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gait laboratory can be

available for measuring

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expected to posses a

oxygen uptake or

combined

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pressure beneath the

kinetic/kinematic

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feet

systems, with

ambulatory EMG, as well

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as facilities for making

videotapes.

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KINEMATICS ?
- Camera by using infrared radiations measures the

position of the markers

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FORCE PLATFORM / FORCEPLATE
- Usual methods of displaying force platform data is the

butterfly diagram

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ELECTROMYOGRAPHY (EMG)

EMG measures the electrical activity of a contracting

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muscle during different phases of gait cycle

1- Surface electrodes- Not suitable for deep muscles like

iliopsoas.

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2- Fine wire electrodes-
3- Needle electrodes-

MEASURING ENERGY CONSUMPTION

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Oxygen consumption-
- measurements of oxygen uptake
- while not particularly pleasant for the subject (who

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has to wear face mask or mouth piece)

- Practical
Whole body calorimetry-
- most accurate way but quite impractical

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- subject is kept in an insulated chamber for measuring

the heat output of the body

Physiological Cost Index: less accurate

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PCI = (Walking HR ? Resting HR)

Walking Speed in m/min

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Thank You.